British Journal of Anaesthesia 92 (6): 793±9 (2004)

DOI: 10.1093/bja/aeh139 Advance Access publication April 30, 2004

CLINICAL INVESTIGATIONS
Evaluation of simple criteria to predict successful weaning from
mechanical ventilation in intensive care patients
T. S. Walsh*, S. Dodds and F. McArdle

Anaesthetics, Critical Care and Pain Medicine, New Royal In®rmary of Edinburgh, Little France,
Edinburgh, Scotland EH16 4SU, UK
*Corresponding author. E-mail: tim@walsh.sol.co.uk

Background. There is increasing evidence that weaning protocols improve outcome from
mechanical ventilation, but it is unclear how best to implement such protocols in large intensive
care units. We evaluated a checklist of simple bedside criteria to determine whether it could
be used reliably to predict successful discontinuation of mechanical ventilation.
Methods. We carried out a prospective observational cohort study in a 12-bedded general
intensive care unit (ICU). We developed a checklist of metabolic, cardiorespiratory and neuro-
logical criteria that suggested that patients should start the weaning process. We performed
daily assessments throughout ICU stay and recorded whether the criteria were met. Ultimate
ventilator independence was used as the reference standard.
Results. We studied 325 sequential admissions to the ICU. Data were available for 98% of
patients; 97% of admissions were mechanically ventilated on admission to ICU. Overall, 205 of
the 308 ventilated patients (67%) achieved ventilator independence during ICU admission; the
other patients died or were transferred ventilated to other ICUs. Eighty-three per cent of the
patients who achieved ventilator independence met the set criteria. Ful®lling the criteria was a
moderately strong predictor of ultimate ventilator independence: speci®city 89%, positive pre-
dictive value 94%, positive likelihood ratio (LR) 7.6. When we analysed data by the day from
admission on which patients were examined, the test was a strong predictor of subsequent
ventilator independence when criteria were met by day 1 (LR 11.1) or day 2 (LR 6.9), but
weaker when met by more than/equal to 4 days (LR <3). Patients who met criteria after more
than/equal to 4 days often had prolonged weaning and a high incidence of re-intubation.
Patients who achieved ventilator independence without ful®lling the criteria (n=35) had a short
duration of mechanical ventilation (median 2 days, interquartile range 1±3 days). The most
frequent reason for failing criteria before ventilator independence was a PaO2/FIO2 ratio less
than 24 kPa (49% of cases).
Conclusions. A simple checklist can assist nurse assessment of suitability for weaning and
could be used as a trigger to commence a weaning protocol. The day on which criteria are met
is a useful way of stratifying patients for likely patterns of weaning.
Br J Anaesth 2004; 92: 793±9
Keywords: monitoring, diagnostic test; monitoring, intensive care; ventilation, mechanical;
ventilation, weaning
Accepted for publication: January 7, 2004

The process of weaning from mechanical ventilation is decreases the availability of ICU beds, and can adversely
central to the management of critically ill patients. Delayed affect patient outcome.1 The process of discontinuing
or unnecessarily prolonged weaning increases intensive care mechanical ventilation is complex and has been considered
unit (ICU) length of stay, increases the cost of ICU care, to occur in several stages. First, the patient must recover

Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2004
 Walsh et al.
suf®ciently from the acute derangements in physiology that
complicated their episode of critical illness to consider
commencing the process of weaning. Secondly, the patient
must undergo progressive reductions in ventilator support
until a point is reached where he/she is capable of
spontaneous breathing. Thirdly, the patient must be discon-
nected from the ventilator, extubated, and breathe spon-
taneously. Various strategies have been suggested to
identify patients that are suitable for weaning and to
manage patients during the weaning process.2±5 The opti-
mum strategy is controversial, but it is recognized that
weaning protocols are important in order to avoid delays in
the weaning process.1 Evidence-based appraisal of the
literature suggests that physiological tests for weaning
success have low predictive power for most groups of
critically ill patients. A recent systematic review concluded
that the implementation of weaning protocols, particularly
when carried out by non-physician health care workers, was
likely to have a major impact on weaning outcomes.4
Successful implementation of weaning protocols requires
criteria that enable staff to identify patients who have a
high probability of being successfully disconnected from
mechanical ventilation so that the weaning protocol can be
initiated. Ideally these criteria should be simple, easy to
collect, have low or insigni®cant cost, and predict subse-
quent weaning and extubation success. Such criteria are
likely to be speci®c to individual ICUs because of hetero-
geneity in case mix and organization between units. We
carried out a prospective, single-centre study to evaluate the
ability of a checklist of simple cardiorespiratory, neuro-
logical, and metabolic criteria to predict outcome from
mechanical ventilation. Our aim was to evaluate the
possible utility of these criteria to trigger a nurse-led
weaning protocol.
Methods
Patients and setting
All patients admitted to the ICU of the Royal In®rmary of
Edinburgh, Scotland were eligible for daily assessment
during the study period (1/4/01 to 11/9/01; 164 consecutive
days). Data were collected as a prospective audit, and as no
interventions occurred the local ethics committee did not
consider relative/patient consent necessary. The 12 bed
general ICU admits about 700 patients annually comprising
an approximate mix of 50% surgical (including about 50
liver transplants annually), 40% medical, and 10% trauma.
The only planned admissions to the ICU are post-liver
transplant patients; all other admissions come from emer-
gency referrals. The unit does not routinely manage post-
cardiac surgery patients or isolated neurotrauma. All
admissions have data entered into the Scottish Intensive
Care Society (SICS) Audit Group database.6 This was used
to cross check completeness of patient data. The annual ICU
audit report for the year immediately preceding the study
794
Table 1 The weaning checklist used
Cooperative and pain free
Good cough re¯ex to tracheal suctioning
PaO2 to FIO2 ratio >24 kPa
Peep <10 cm H2O
Hb >7 g dl±1
Axillary temperature between 36 and 38.5°C
Plasma K+ concentration >3.0 and <5.0 mmol litre±1
Plasma Na+ concentration >128 and <150 mmol litre±1
Inotropes reduced or unchanged over previous 24 h
Spontaneous ventilatory frequency >6 min±1
showed the following unit characteristics: 676 admissions
with a median (range) APACHE II score of 20 (3±51).
Hospital mortality was 39.9% (SMR 1.08, measured against
APACHE II prediction).
Weaning criteria
We used simple bedside criteria regarding metabolic,
cardiovascular, respiratory, and neurological status to assess
patients (Table 1). The aim of the criteria was to provide a
checklist that, if all ®elds were met, suggested that acute
physiological derangement had improved suf®ciently to
consider starting the weaning process. We termed these
`weaning criteria' and considered that the criteria were met
when all criteria were present simultaneously. The criteria
were developed locally by a process of literature review and
by consensus. First, a group of two consultants and two
experienced nurses reviewed published studies, in particular
systematic reviews of the literature.3 5 Secondly, a checklist
was derived pragmatically and discussed generally among
ICU staff. Our original criteria had a higher level of
haemoglobin concentration (9 g dl±1) and a lower level of
PEEP (5 cm H2O) than most staff considered necessary for
weaning. We therefore modi®ed the original criteria for
these items. The ®nal criteria included a PEEP level <10 cm
H2O, re¯ecting current trends to maintain high levels of
PEEP7 in patients recovering from acute lung injury, and a
haemoglobin concentration >7 g dl±1, re¯ecting evidence
suggesting that restrictive transfusion practice does not
prolong ventilation requirements in the critically ill.8
Data collection
Patient's charts were examined on each day of admission by
one of the authors (S.D. or F.McA.), and the presence or
absence of each weaning criterion noted. Daily data for all
admissions were entered onto a spreadsheet (Excel, version
4.0, Microsoft Corp.) for subsequent analysis. The day on
which complete ventilator independence was successfully
achieved was recorded, together with the day of discharge or
death. For patients who required re-intubation and ventil-
ation, the day of ventilator independence was the day on
which ventilator independence was achieved for the ®nal
time during that ICU admission. Re-admissions to intensive
care for mechanical ventilation were treated as separate
 Weaning criteria in ventilated patients
Fig 1 Outcomes in relation to the weaning criteria checklist for the patients studied.
ventilation episodes. Patients ventilated via a tracheostomy
tube were considered ventilator independent when they
were no longer connected to the ventilator.
Existing weaning practice
At the time of the study, weaning decisions were largely
physician led. No formal screening protocol for suitability
for weaning was used in the unit. Instead, medical staff
assessed patients as part of routine daily review. Weaning
strategies were individualized to patients, and extubation
was only carried out after consultation with medical staff.
Analysis
We calculated the sensitivity and speci®city, positive and
negative predictive values, and positive and negative
likelihood ratios (LRs) for the weaning criteria to predict
successful ventilator independence during ICU stay. We
also calculated the positive LRs depending on the day from
admission that weaning criteria were assessed, and plotted
the time taken from ®rst meeting the weaning criteria to
achieving ventilator independence.
Results
There were 325 admissions to the ICU during the study
period. No data were available for eight (2%) admissions; a
further nine (3%) admissions were evaluated, but were
never intubated and mechanically ventilated. The charac-
teristics of the patients studied were: median age 61 (range
12±92) yr, mean APACHE II score 20.7 (range 2±50), ICU
mortality 28%, median ICU length of stay 1.7 days. Data
from the Scottish Intensive Care Society Audit Group
database showed the following characteristics for the eight
795
patients for whom weaning data were not available:
mean APACHE II 18.1 (range 7±36; 1 readmission);
median ICU length of stay 5.5 days; and all these patients
survived ICU.
Data concerning weaning criteria were evaluated for the
308 admissions that were mechanically ventilated on
admission to the ICU. A description of ventilation outcomes
with reference to weaning criteria for these admissions is
shown in Figure 1.
Predictive value of the weaning criteria
We examined the ability of the weaning criteria to predict
subsequent ventilator independence. For this analysis we
excluded admissions that were discharged ventilator
dependent to other facilities, because ultimate ventilation
outcome, which was the reference standard, was unknown
for these individuals. These 14 patients were all transferred
to ICUs in other hospitals because of ICU bed shortages.
After these exclusions, a total of 180 admissions met the
weaning criteria and 114 admissions did not during their
ICU stay (Fig. 1). Two patients were classi®ed as becoming
ventilator independent, but never met the weaning criteria,
because they were extubated as part of terminal care. These
were excluded from the analysis. The ability of weaning
criteria to predict ventilator independence for the remaining
292 admissions is summarized in Table 2.
Importance of the day on which weaning criteria
®rst met
The ventilation outcomes for the patients who met the
weaning criteria, subdivided into the day on which weaning
criteria were ®rst met, are described in Figure 2. These data
 Walsh et al.

Table 2 Ability of weaning criteria to predict ventilator independence

Achieved ventilator independence

during ICU stay?

Yes No Total

Met weaning criteria? Yes 170 10 180

No 33 79 112
Total 203 89 292
Overall test data
Sensitivity 84%
Speci®city 89%
Positive likelihood ratio 7.6
Negative likelihood ratio 0.18
Positive predictive value 94%
Negative predictive value 70%

indicated that the majority of admissions achieved ventilator

independence within 1 day if weaning criteria were ®rst met
on day 1 of admission, but were less certain when weaning
criteria were ®rst met on day 2 or more.
We calculated positive LR for the test for data overall and
by the day from ICU admission on which a patient was
assessed. For this analysis, we excluded patients who were
discharged from our unit ventilator-dependent (n=14) for
the reasons described above, but included all other patients.
We then considered all patients who were in the ICU on
each day from admission. For example, for calculating the
LR on day 2, we excluded patients with a length of stay of
less than/equal to 1 day (n=41), and examined the remaining
patients in the dataset (n=250). Any patient who met the test
criteria on days 1 or 2 or both (n=91) was considered as `test Fig 2 Duration of mechanical ventilation in relation to the day from
positive'. LRs are presented for the test performed on admission that the weaning criteria were ®rst met.

various days from ICU admission in Table 3.

Patients who achieved ventilator independence, but

Patients who met weaning criteria, but were
subsequently re-intubated
Of the 178 patients who met the weaning criteria, nine
patients (5%) required re-intubation within 48 h of ®rst
extubation. Eight of these patients ®rst met the criteria in
more than 4 days from admission. Only one of these patients
died during their ICU stay.
never met weaning criteria
The 35 patients who were ventilated at ICU admission,
achieved ventilator independence, but who never ful®lled
the weaning criteria had a median (1st, 3rd quartile; range)
number of days from admission to achieving ventilator
independence of 2 (1, 3; 1±18) days. The median ICU length
of stay of these patients was 4 (2, 6; 1±19) days. The reasons
for not meeting the weaning criteria on the day ventilator
independence was achieved are summarized in Table 4.

Patients who met weaning criteria, but failed them

on at least one subsequent ICU day
Of the 178 patients who met the weaning criteria there were
17 (9.6%) who did not require subsequent re-intubation, but
failed the criteria on at least 1 day after meeting the criteria
for the ®rst time. Twelve of these 17 patients did not ®rst
meet the criteria for more than 4 days after admission
(median (IQR, range) day ®rst met criteria: 8 (3.9; 0±34)
days). Only one of these patients (who ®rst met criteria after
34 days) subsequently died in ICU.
Discussion
We have assessed the ability of simple criteria to predict
ultimately successful discontinuation of mechanical ventil-
ation. Our aim was to evaluate this as a checklist that the
ICU nurse could use to identify patients who have reached a
stage in their critical illness at which initiating the process of
weaning should be considered. The rationale for the study
was that weaning protocols have been shown to decrease
ventilation time, the associated length of ICU stay, and the

796
 Weaning criteria in ventilated patients
Table 3 Positive likelihood ratios of the test depending on the day from ICU
admission on which the patient was examined. Data for patients who were
discharged ventilator-dependent were excluded from the analysis
Day from ICU admission Patients still Positive likelihood
on which patient assessed in the ICU ratio
1 294 11.1
2 250 6.9
3 159 3.2
4 114 2.1
>4 93 2.8
cost of ICU care.1 For these to occur effectively, ICU nurses
or other non-physician workers need a simple tool that gives
them con®dence that a patient has a high probability of
achieving ventilator independence.
Jaeschke and colleagues have considered how to assess
the value of a weaning test in critically ill patients.9 They
suggested that study data should be examined in a
systematic manner using a number of questions.
Was there an independent, blind comparison with a
reference standard?
The reference standard in our study was whether the patient
was ultimately successfully weaned from mechanical
ventilation. We de®ned this as disconnection from the
ventilator, and failure to wean as death without disconnec-
tion from the ventilator. We excluded patients who were
discharged ventilator-dependent to other acute ICUs as a
result of ICU bed shortages, because ultimate weaning
outcome in these individuals was not known. We believe
that the reference standard used in the study was reasonable,
although it was impossible to blind investigators from this
outcome. The weaning checklist data were collected
independently and clinicians and nursing staff weaning the
patients did not see the checklist results. However, complete
concealment of the data was not possible or ethical and it is
likely that clinicians used some of these data when they
made ventilation decisions. Collecting the checklist data
independently was the most feasible method of blinding and
minimized the chance of bias.
Did the patient sample include an appropriate
spectrum of patients to whom the diagnostic test
would be applied in clinical practice?
We designed our study to include all patients admitted to the
ICU during the study period. We validated the completeness
of our dataset against an independent audit database that
tracks all patients admitted to the ICU.6 We obtained data on
98% of eligible admissions, and characterized the admis-
sions of the eight patients for whom no data were available.
We therefore consider selection bias extremely unlikely.
We also characterized the illness severity (APACHE II
diagnosis), physical characteristics, ventilation outcome,
797
Table 4 Reasons for not meeting the weaning criteria at the assessment
preceding ventilator independence, for those patients who achieved ventilator
independence without ever meeting weaning criteria (n=35). All values
number (%)
PaO2/FIO2 ratio <24 kPa 17 (49)
Unstable cardiovascular status 3 (9)
Patient neurologically impaired/uncooperative 6 (18)
No/inadequate spontaneous respiratory effort 4 (11)
Extubated as part of terminal care 2 (6)
Reason not recorded 3 (9)
length of stay, and mortality of the cohort to enable
comparisons with other settings. This should enable others
to assess the applicability of our ®ndings to other ICU
populations.
Did the results of the test being evaluated in¯uence
the decision to perform the reference standard?
The properties of the weaning criteria test would be
distorted if they had in¯uenced weaning decisions during
the study because this would have introduced veri®cation
bias.10 During the data collection, weaning criteria were
recorded by an individual who was not involved in making
weaning decisions, but as discussed above it was impossible
to blind clinicians to the components of the checklist as this
would have been impractical and unethical. Blinding of test
information is a common confounding factor in studies of
weaning criteria. Our question related speci®cally to the
association between ful®lling all components of the check-
list and ultimate ventilation outcome. Although it is likely
that individual physiological variables were used by
clinicians during patient evaluation, we think it unlikely
that this had a major confounding effect on our reference
standard.
What are the sensitivity, speci®city, and likelihood
ratios for the test?
We have presented the overall sensitivity and speci®city of
the test for correctly identifying patients who are success-
fully disconnected from the ventilator and discharged from
the ICU. For nurse-led weaning a test is needed that is
simple, quick, and gives the nurse at the bedside con®dence
that the patient will eventually become ventilator indepen-
dent having achieved his/her current status. The ideal test
should have a high speci®city, because this allows a high
degree of con®dence that the outcome of interest, namely
ventilator independence, will occur.11 In our population the
weaning criteria had, overall, a moderately high speci®city
(89%), which should allow the ICU nurse to be con®dent
that considering the patient for weaning is appropriate.
Sensitivity, speci®city, and predictive values are of
limited value for predicting outcomes in weaning studies
because they generally apply to single cut-off points. We
calculated LR, which allow an assessment of changes in pre-

Table 5 Simulations of the effect the weaning criteria have on post-test
probability of successful weaning at different levels of pre-test probability.
Pre-test probabilities have been set at 20, 40, and 60% to re¯ect possible
levels of probability in a variety of types of ICU patient
Day from ICU Positive Pre-test
admission on which LR probability
patient assessed (%)
1 11.1 20
40
60
2 6.9 20
40
60
3 3.2 20
40
60
4 2.1 20
40
60
>4 2.8 20
40
60
test probability.5 Our overall positive LR of 7.6 and
negative LR of 0.18 correlate with clinically important
changes in probability suggesting that the weaning checklist
may be clinically useful. Plotting the number of patients
who were still ventilator dependent in relation to the day
from ICU admission on which the criteria were ®rst met
(Fig. 2) suggested that this factor was an important
determinant of the value of the test. We therefore calculated
positive LRs for the weaning criteria depending on the day
from admission on which the test was performed. This
showed that the test had a large effect on the post-test
probability if weaning criteria were met on the ®rst full ICU
day, a moderate effect on the second day, and smaller
effects on subsequent days. We have used these LRs to
simulate the pre- to post-test probability changes at various
levels of pre-test probabilities on different days of admis-
sion (Table 5). These changes were measured from a Fagan
nomogram.12 This simulation clearly shows that if the
criteria were met on days 1 or 2 from admission a clinically
signi®cant increase in post-test probability occurs irrespec-
tive of the estimated pre-test probability of ultimate
ventilator independence. When met on day 3 or more the
changes in probability are more modest, consistent with
positive LRs of 2±4. These patients took longer to achieve
ventilator independence, had a high incidence of re-
intubation after ®rst meeting the criteria (31%), and in
many cases (46%) failed the weaning criteria on subsequent
days. If our weaning criteria were used as part of a daily
nursing checklist, broadly two groups of patients would be
identi®ed. First, patients who ful®l the criteria during the
®rst 1±2 days of ventilation are weaned successfully and
quickly in the majority of cases. These patients comprised
40% of all admissions during the study period. For these
patients the weaning criteria could be used to trigger a
reduction in sedation, a spontaneous breathing trial, or
Walsh et al.
protocolized reduction in ventilator support, and subsequent
extubation without involvement of physicians. Secondly,
the group who ®rst met the criteria in more than/equal to 3
Post-test
days from ventilation had a more variable weaning duration.
probability For these patients, the criteria could also be used to trigger a
(%) reduction in sedation and ventilatory support, but additional
evaluation by medical staff, such as a formal assessment of
75
85 respiratory pattern, cardiovascular responses and comfort,
95 may be advisable. These patients may be less suited to a
65 nurse-led protocol, but the weaning criteria could be used as
80
90 a trigger to involve more experienced staff or a `weaning
45 team'.
65 We found that about 18% of patients who were weaned
80
35 successfully failed the weaning criteria at the assessment
60 immediately preceding disconnection from the ventilator.
75 This resulted in a relatively low sensitivity (84%) and
40
65 negative predictive value (70%). For a test designed to guide
80 patients towards an intervention (namely weaning), this
false negative rate is only of concern if it results in
unnecessary delays in the outcome of interest. In our
patients, the commonest reasons for failing the weaning
criteria immediately before ventilator independence were
PaO2/FIO2 ratio, neurological status, and spontaneous
respiratory effort in almost 70% of cases (Table 4). These
patients most likely progressed rapidly to extubation
because of rapid improvement in their condition and
reduction in sedation level within the 24 h before the next
weaning criteria were charted. For these patients, failing the
criteria was not apparently associated with delayed weaning
so it is unlikely that using the criteria as part of a protocol
would introduce delays in recognizing patients ready to
wean. In practice, the aim of criteria should be to encourage
continual assessment rather than a checklist at a ®xed time
point.
We did not formally include a review of sedation in our
study, but our data emphasize the importance of daily
assessment of sedation status in conjunction with a weaning
protocol. Daily cessation or reduction in sedation may have
decreased the number of failures as a result of inadequate
spontaneous respiratory effort or impaired neurological
status. Previous studies have shown that daily sedation
cessation reduces ICU length of stay.13 This approach is
likely to be particularly effective if combined with regular
assessment of weaning criteria to trigger a weaning
protocol.
In conclusion, we have shown that a simple bedside
weaning checklist can reliably predict patients who achieve
ventilator independence, particularly if the day from
ventilation on which these criteria were ®rst met is
considered. These criteria are a potential method of
introducing nurse-led weaning protocols.
Acknowledgements
Supported in part by Datex-Ohmeda and by the Royal In®rmary of
Edinburgh Intensive Care Unit Research Fund.
798
 Weaning criteria in ventilated patients
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